[Changes in renal function induced by anesthesia]

Abstract

The rate of urine formation and its composition are influenced by the different drugs used during surgery. Anaesthetics act on renal function, not only directly, but also by producing changes in cardiovascular function and in neuroendocrine activity. Many factors may be incriminated: lowered blood pressure and cardiac output, increased sympathetic outflow (renal nerve stimulation and increased plasma catecholamines), increased release of renin, angiotensin and vasopressin. The effects of anaesthetics on the kidney go beyond a simple change in basal haemodynamics and include, for some drugs, an alteration in the ability for the kidney to autoregulate its blood flow and glomerular filtration rate. Studies on toad bladders showed a decrease in transport of water, sodium and organic anions. But, in fact, renal effects of anaesthetics in man and animals depend on the species, the anaesthetic and the method used to study the effect. Most barbiturates and inhalational anaesthetics tend to decrease renal blood flow (RBF) and glomerular filtration rate (GFR). These trends are gradually reversed during recovery. The effects of ketamine and diazepam are not clearly defined. Morphine and fentanyl decrease urine flow and GFR, whilst RBF increases or decreases, depending on whether a direct or indirect measurement technique was used. Muscle relaxants have little effect on renal function. Spinal and epidural anaesthesia only slightly decrease GFR and RBF in proportion to the decrease in mean arterial pressure. Obviously, the preexisting intravascular volume and the quantity of intravenous fluids given strongly influence the renal response to spinal and epidural anaesthesia. Some studies have shown that urine flow rate, creatinine clearance, urinary sodium excretion and RBF are reduced during mechanical ventilation with positive end-expiratory pressure. Surgery itself influences renal function by inducing alterations in prerenal haemodynamics. Operative stress leads to an increase in circulating catecholamines and angiotensin. Significant fluid shifts, excessive blood loss and redistribution of a third space may lead to a prerenal oliguric state, increasing secretion of vasopressin. Acute renal failure (ARF) is a frequently lethal complication of critical surgical illness, due to a variety of factors which interfere with glomerular filtration and tubular reabsorption, such as renal hypoperfusion or nephrotoxic insults. In fact, the initiating aggression ultimately culminates in the development of one or more of the maintenance factors (decreased tubular function, tubular obstruction, decreased GFR and RBF) that reduce urine flow and osmolar excretion. Good management during the perioperative period tends to minimize the risk of developing ARF.